Information Notice 1990-63, Management Attention to the Establishment and Maintenance of a Nuclear Criticality Safety Program

Management Attention to the Establishment and Maintenance of a Nuclear Criticality Safety Program

ML031140014
Person / Time
Site:	Beaver Valley, Millstone, Hatch, Monticello, Calvert Cliffs, Dresden, Davis Besse, Peach Bottom, Browns Ferry, Salem, Oconee, Mcguire, Nine Mile Point, Palisades, Palo Verde, Perry, Indian Point, Fermi, Kewaunee, Catawba, Harris, Wolf Creek, Saint Lucie, Point Beach, Oyster Creek, Watts Bar, Hope Creek, Grand Gulf, Cooper, Sequoyah, Byron, Pilgrim, Arkansas Nuclear, Three Mile Island, Braidwood, Susquehanna, Summer, Prairie Island, Columbia, Seabrook, Brunswick, Surry, Limerick, North Anna, Turkey Point, River Bend, Vermont Yankee, Crystal River, Haddam Neck, Ginna, Diablo Canyon, Callaway, Vogtle, Waterford, Duane Arnold, Farley, Robinson, Clinton, South Texas, San Onofre, Cook, Comanche Peak, Yankee Rowe, Maine Yankee, Quad Cities, Humboldt Bay, La Crosse, Big Rock Point, Rancho Seco, Zion, Midland, Bellefonte, Fort Calhoun, FitzPatrick, McGuire, LaSalle, Fort Saint Vrain, Shoreham, Satsop, Trojan, Atlantic Nuclear Power Plant
Issue date:	10/03/1990
From:	Cunningham R NRC/NMSS/IMNS
To:
References
IN-90-063, NUDOCS 9009270046
Download: ML031140014 (11)

UNITED STATES

NUCLEAR REGULATORY COMMISSION

OFFICE OF NUCLEAR MATERIAL SAFETY AND SAFEGUARDS

WASHINGTON, D.C. 20555 October 3, 1990

NRC INFORMATION NOTICE NO. 90-63: MANAGEMENT ATTENTION TO THE ESTABLISHMENT

AND MAINTENANCE OF A NUCLEAR CRITICALITY

SAFETY PROGRAM

Addressees

All fuel cycle licensees and other licensees possessing more than critical

mass quantities of special nuclear material.

Purpose

This information notice is provided to alert addressees to an incident resulting

from inadequate management attention to the establishment and maintenance of.a

nuclear criticality safety program. The licensee's inattention to Information

Notice No. 89-24, Nuclear Criticality Safety, dated March 6, 1989, may have been

a contributing factor in the incident. It is expected that licensees will

review this information and the 1989 Information Notice for applicability to

their facilities and consider actions, as appropriate, to avoid similar problems.

However, suggestions contained in this Information Notice do not constitute U.S.

Nuclear Regulatory Commission (NRC) requirements; therefore, no specific action

or written response is required.

Description of Circumstances

In March 1990, a licensee's routine sample analysis for a Raschig-ring filled

waste collection tank (a non-favorable geometry vessel) yielded a concentration

of approximately 2 grams of highly enriched uranium per liter of solution.

Contents of the tank are normally transferred to a second larger tank

(a non-favorable geometry vessel without Raschig rings) at a release limit of

0.01 grams uranium per liter. The analysis of a second sample confirmed that a

major upset had occurred in the waste collection system. Consequently, the

waste processing area was shutdown, and the waste collection tank was isolated.

Corrective actions were taken to recover the uranium (in excess of 4 kilograms).

The licensee's investigation team concluded that the contents of two favorable

diameter 11-liter cylinders, one or both containing high concentration solution, had been dumped into a sump used to pump solution to the waste collection tank.

By procedure, operators were allowed to dump low concentration uranium solutions

into the sump after receiving authorization and key access from supervisors.

Findings which supported the team's conclusion are: (1) the quantity of uranium

in the tank, (2) an operator's statement that two 11-liter cylinders of process

.4 -

IN 90-63 October 3, 1990 solution were poured into the sump, (3) traces of yellow uranium solids in the

sump and filter, and (4) ineffective isolation of the sump caused by failure to

perform maintenance and to conduct access control. The investigation team also

speculated that one or both of the 11-liter cylinders had been mislabelled based

on an operator's statement that 11-liter cylinders were mislabelled in the past

and the team's observation of an 11-liter cylinder of high concentration

solution that was improperly labelled.

The failure of the licensee's management control systems resulted in an unsafe

transfer of the uranium solution through the sump into the collection tank.

Both the sump and the collection tank had risks of a criticality event and no

controls remained. Even though the administrative control led to the detection

of the high concentration of uranium and precluded its transfer to the second

larger tank, an additional unsafe transfer could have occurred with only one

unlikely, independent, and concurrent change in process conditions (viz.,

recording the wrong analysis or using the wrong sample analysi; 'etc.). In both

the actual incident and the postulated case of transfer of concentrated solution

to the second larger tank, controls to satisfy the double contingency principle

were not implemented.

Discussion:

This event and those events described in the 1989 Information Notice emphasize

the need for continuing vigilance in providing a sound nuclear safety program.

Although the licensee had a copy of the 1989 Information Notice on file, no

action was taken to avoid similar events. Some of the recommendations made by

the licensee's investigation team are listed below. Licensees are encouraged to

review these recommendations, the 1989 Information Notice, and their own programs

to ensure nuclear criticality safety.

- Eliminate sumps and install piping to transfer waste solutions, thereby, eliminating the use of the 11-liter cylinders in this application.

- Evaluate the procedures and practices for affixing labels to 11-liter

cylinders in all process areas.

- Install In-line detectors and totalizers on all streams to waste collection

tanks containing Raschig rings. Consider automatic shutoff of the flow

when a detected uranium concentration exceeds an acceptable nuclear

criticality control limit.

- Install additional controls on all streams to the collection tank without

Raschig rings. This should include an evaluation of interlocked valves, as well as valves controlled by in-line detectors or conductivity meters

connected to an alarm system.

,

IN 90-63 October 3, 1990 Develop training material for, and train, first responders to unusual

events.

Retrain supervisory personnel on issues important to safety, labor

relations, training, and emergency response.

Evaluate the existing training program to ensure that personnel are trained

and knowledgeable of assigned tasks in waste processing areas and of

nuclear criticality safety issues, including selected criticality accident

histories.

Reevaluate all nuclear criticality safety analyses to ensure proper

application of the double contingency principle, with emphasis on unsafe

geometry vessels.

Reevaluate the audit and inspection programs to ensure that management

control systems are being properly implemented.

Review operating procedures for accuracy and completeness.

Retrain personnel with procedural requirements with emphasis on mandatory

compliance.

No specific action or written response is required by this Information Notice.

If you have any questions, please contact the technical contacts listed below or

the Regional Administrator of the appropriate regional office.

84 ard E. CunnInamDiretor

}ivision of Industrial and

Medical Nuclear Safety

/ '

Office of Nuclear Material Safety

and Safeguards

Technical Contacts: Edward McAlpine, Region II

(404) 331-5547 W. Scott Pennington, NMSS

(301) 492-0693 Attachments:

1. Information Notice No. 89-24, Nuclear Criticality Safety, dtd March 6, 1989

2. List of Recently Issued

NMSS Information Notices

3. List of Recently Issued

NRC Information Notices UNITED STATES

NUCLEAR REGULATORY COMMISSION

OFFICE OF NUCLEAR MATERIAL SAFETY AND SAFEGUARDS

WASHINGTON, D.C. 20555 March 6, 1989 NRC INFORMATION NOTICE NO. 89-24: NUCLEAR CRITICALITY SAFETY

Addressees

All fuel cycle licensees and other licensees possessing more than critical mass

quantities of special nuclear material.

Purpose

This information notice is being provided to alert addressees to potential

problems resulting from inadequate administration and application of the

double contingency principle in establishing nuclear criticality safety limits

and controls. It is expected that licensees will review the information for

applicability to their facilities and consider actions, as appropriate, to

avoid similar problems. However, suggestions contained in this information

notice do not constitute U.S. Nuclear Regulatory Commission (NRC) requirements;

therefore, no specific action or written response is required.

Description of Circumstances

The double contingency principle, as used in ANSI/ANS-8.1-1983*, states that

"Process designs should, in general, incorporate sufficient factors of safety

to require at least two unlikely, independent, and concurrent changes in process

conditions before a criticality accident is possible." Proper application of

the double contingency principle provides assurance that no single error or

loss of a control will lead to the possibility of a criticality accident.

In March 1988, an NRC licensee was authorized to operate a new pilot plant

operation involving highly enriched uranium solution. Provisions were made

to remove liquid scrap in 2.5 liter bottles from the operations area (Area 1).

Because of increased quantities of scrap solution and lack of temporary storage, an alternate liquid-handling process was established. The alternate method

allowed both dilute and concentrated scrap solution to be stored in 11-liter

bottles in the same area., After an analysis of a single sample, the 11-liter

bottles of dilute scrap solution were to be transferred to an adjacent area

(Area 2) and emptied into mass-limited 55-gallon drums.

• American National Standard For Nuclear Criticality Safety in Operations With

Fissionable Materials Outside Reactors, ANSI/ANS-8.1-1983.

-8te22ee6 I fp

'-I IN 89-24 March 6, 1989 During an inspection in July 1988, NRC personnel recognized that an operator

could inadvertently transfer an unsafe quantity of scrap solution into a drum

by either selecting the wrong bottle of solution or as a result of an erroneous

sample analysis. Such an unsafe transfer could have been effected with only

one unlikely, independent, and concurrent change in process conditions (viz.,

selecting the wrong bottle, recording the wrong analysis or using the wrong

sample analysis, etc.) and hence, the double contingency principle was not

satisfactorily implemented. Because this method of handling 11-liter bottles

was somewhat similar to the handling method contributing to the Wood River

Junction accident in 1964, the NRC inspectors expressed concern. The licensee

immediately ceased all scrap handling and subsequently shutdown the entire

process area to review the safety limits and controls.

Further review disclosed that the nuclear criticality safety analyst who had

analyzed the process before startup was not familiar with the alternate scrap- solution-handling procedure. Administrators within the licensee's safety group

had approved the change because a safe mass limit had been imposed on each drum

in Area 2. The licensee claimed that the alternate method of solution-handling, permitted by procedure, had not been used because the material control and

accounting restrictions made the method inefficient.

NRC personnel also noted that Area 2 contained several open 55-gallon drums.

Area 2 was used to remove solids from Raschig ring filled drums which were

used in Area 3 (scrap recovery). Raschig ring filled drums and drums of

chemicals were taken from Area 2 into Area 3. Because a 55-gallon drum was

involved in the Oak Ridge Y-12 accident, NRC personnel expressed concern with

the lack of controls on open drums. The licensee immediately shutdown Areas 2 and 3 so that the nuclear criticality safety limits and controls could be re- examined.

Discussion:

These events highlight the need for continuing vigilance in providing a sound

nuclear safety program. Some of the licensee's actions taken after the inspec- tion are discussed here. Licensees are encouraged to review these actions and

their own vigilance in assuring nuclear criticality safety.

A team led by a safety director from another of the licensee's nuclear facili- ties conducted an immediate audit of the three areas. The team consisted of

safety and production personnel. The audit team confirmed NRC's findings and

identified other safety items.

All nuclear criticality safety analyses were reviewed to ensure proper appli- cation of the double contingency principle. Documentation of analyses has been

revised to provide explicit consideration of the double contingency principle.

The nuclear criticality safety analysis group now reviews all changes to nuclear

criticality limits and controls. The administrative group can no longer approve

seemingly simple changes such as authorizing new mass limits for work stations, based on established safe mass limits.

IN 89-24 March 6, 1989 Production personnel were not involved in establishing nuclear safety limits

and were not familiar with the above-mentioned nuclear criticality accidents.

The safety training program has been revised to include selected accident

histories.

All involved personnel, including production operators, have reviewed all

procedures. Before startup of Areas 1, 2, and 3, procedures were revised to

include nuclear safety limits and controls. Procedures in other plant areas

will be revised to include safety limits.

Liquid scrap from Area 1 is now collected in favorable geometry containers.

After analysis, the solution is transferred to a favorable geometry quaran- tine tank for a second analysis. Then the solution is transferred to uniquely

identified favorable geometry containers, for transfer to the drums in Area 2.

Most 55-gallon drums in Area 2 have been eliminated by engineering redesign.

Barriers and other controls are in place to prevent unauthorized transfer of

drums into Area 3. Engineering studies are underway to eliminate or reduce

the use of all unfavorable geometry containers in Area 3.

No specific action or written response is required by this information notice.

If you have questions about this matter, please contact the technical contacts

listed below or the Regional Administrator of the appropriate regional office.

Richard E. Cunningham Director

Division of Industriai and

Medical Nuclear Safety

Office of Nuclear Material Safety

and Safeguards

Technical Contacts: Gerald Troup, Region II

(404) 331-5566 George Bidinger, NMSS

(301) 492-0683 Attachment: List of Recently Issued NRC Information Notices

Attachment 2 IN 90-63 October 3, 1990 LIST OF RECENTLY ISSUED

NMSS INFORMATION NOTICES

Information Date of

Notice No. Subject Issuance Issued to:

90-62 Requirements for Import 09/25/90 All irradiated gemstone

and Distribution of importers and distributors, Neutron-Irradiated Gems and all non-power reactor

licensees

90-59 Errors in the use of 09/17/90 All medical licensees

Radioactive Iodine-131

90-58 Improper Handling of 09/11/90 All Nuclear Regulatory

Ophthalmic Strontium-90 Commission (NRC) medical

Beta Radiation Applicators

90-56 Inadvertent Shipment of a. 09/04/90 All U.S. Nuclear

Radioactive Source in a Regulatory Commission

Container Thought to be Empty (NRC) licensees

90-50 Minimization of Methane Gas 08/08/90 All holders of operating

in Plant Systems and Radwaste licenses or construction

Shipping Containers permits for nuclear power

reactors

90-44 Dose-Rate Instruments 06/29/90 All NRC licensees

Underresponding to the True

Radiation Fields

90-38 Requirements for Processing 05/29/90 All fuel facility and

Financial Assurance Submittals materials licensees

for Decommissioning

90-35 Transportation of Type A 05/24/90 All U.S. Nuclear Regulatory

Quantities of Non-Fissile Commission (NRC) Licensees

Radioactive Materials

V% Attachment 3 IN 90-63 October 3, 1990 LIST OF RECENTLY ISSUED

NRC INFORMATION NOTICES

Information Date of

Notice No. Subject Issuance Issued to

Requirements for Import 9/25/90 All irradiated

90-62 gemstone importers

and Distribution of

Neutron-Irradiated Gems and distributors, and all non-power

licensees.

Potential for Residual 9/20/90 All holders of

90-61 OLs or CPs for

Heat Removal Pump

Pump Damage Caused By nuclear power

Parallel Pump Interaction reactors.

Availability of Failure 9/20/90 All holders of

90-60 OLs or CPs for

Data In the Government- Industry Data Exchange nuclear power

Program reactors.

Errors In the Use of 9/17/90 All medical

90-59 licensees.

Radioactive Iodine-131 Improper Handling of 9/11/90 All NRC medical

90-58 licensees.

Ophthalmic Strontium-90

Beta Radiation Applicators

Substandard, Refurbished 9/5/90 All holders of OLs

90-57 Potter & Brumfield Relays or CPs for nuclear

Misrepresented As New power reactors.

90-56 Inadvertent Shipment of A 9/4/90 All U.S. Nuclear

Radioactive Source In A Regulatory Com- Container Thought To Be mission (NRC)

Empty licensees.

90-55 Recent Operating Experi- 8/31/90 All holders of OLs

ence on Loss of Reactor or CPs for nuclear

Coolant Inventory While power reactors.

In A Shutdown Condition

83-44 Potential Damage to 8/30/90 All holders of OLs

Supp. 1 Redundant Safety Equip- or CPs for nuclear

ment As A Result of power reactors.

Backflow Through the

Equipment and Floor Drain

System

OL = Operating License

CP = Construction Permit

1I'

IN 90-63 October 3, 1990 - Develop training material for, and train, first responders to unusual

events.

- Retrain supervisory personnel on issues important to safety, labor

relations, training, and emergency response.

- Evaluate the existing training program to ensure that personnel are trained

and knowledgeable of assigned tasks in waste processing areas and of

nuclear criticality safety issues, including selected criticality accident

histories.

- Reevaluate all nuclear criticality safety analyses to ensure proper

application of the double contingency principle, with emphasis on unsafe

geometry vessels.

- Reevaluate the audit and inspection programs to ensure that management

control systems are being properly implemented.

- Review operating procedures for accuracy and completeness.

- Retrain personnel with procedural requirements with emphasis on mandatory

compliance.

No specific action or written response is required by this Information Notice.

If you have any questions, please contact the technical contacts listed below or

the Regional Administrator of the appropriate regional office.

JVR chhard E. Cunningham, Director

() Division of Industrial and

Medical Nuclear Safety

Office of Nuclear Material Safety

and Safeguards

Technical Contacts: Edward McAlpine, Region II

(404) 331-5547 W. Scott Pennington, NMSS

(301) 492-0693 Attachments:

1. Information Notice No. 89-24, Nuclear Criticality Safety, dtd March 6, 1989

2. List of Recently Issued

NMSS Information Notices

3. List of Recently Issued

NRC Information Notices

EKraus: 9/ /90

• See previous concurrence

OFC:IMUF:* IMUF:* IMUF:* IMUF:* IMSB:* Df  : D/IMNS:*

_________________________________________-_------t- ___________

NAME:WSPennington:mh:RW-ilson:VLTharpe:GHBidinger:CHaughney:Gy :'-S 1 lom:RECunningham:

DATE:9/24/90:. 9/24/90:9/24/90: 9/24/90: 9/24/90: 9t 90: 9/25/90:

~- - OFFICIAL RECORD COPY

IN 90-63 October 3, 1990 - Develop training material for, and train, first responders to unusual

events.

- Retrain supervisory personnel on issues important to safety, labor

relations, training, and emergency response.

- Evaluate the existing training program to ensure that personnel are trained

and knowledgeable of assigned tasks in waste processing areas and of

nuclear criticality safety issues, including selected criticality accident

histories.

- Reevaluate all nuclear criticality safety analyses to ensure proper

application of the double contingency principle, with emphasis on unsafe

geometry vessels.

- Reevaluate the audit and inspection programs to ensure that management

control systems are being properly implemented.

- Review operating procedures for accuracy and completeness.

- Retrain personnel with procedural requirements with emphasis on mandatory

compliance.

No specific action or written response is required by this Information Notice.

If you have any questions, please contact the technical contacts listed below or

the Regional Administrator of the appropriate regional office.

Richard E. Cunningham, Director

Division of Industrial and

Medical Nuclear Safety

Office of Nuclear Material Safety

and Safeguards

Technical Contacts: Edward McAlpine, Region II

(404) 331-5547 W. Scott Pennington, NMSS

(301) 492-0693 Attachments:

1. Information Notice No. 89-24, Nuclear Criticality Safety, dtd March 6, 1989

2. List of Recently Issued

NMSS Information Notices

3. List of Recently Issued

NRC Information Notices

EKraus: 9/ /90

• See previous concurrence

OFC:IMUF:* IMUF:* IMUF:* IMUF:* IMSB:* DD/IMNS: D/IMNS:*

NAME:WSPennington:mh:RWilson:VLTharpe:GHBidinger:CHaughney:GSjoblom:RECunningham:

DATE:9/24/90: 9/24/90:9/24/90: 9/24/90: 9/24/90: 9/ /90: 9/25/90:

~-ncrrTrT D~nD1%0nnw

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IN 90-

Septe er , 1990

Pag of 3

- Development and implementation of training material f irst responders to

unusual events.

- Retrain supervisory personnel on Issues importan to safety, labor

relations, training, and emergency response.

- Evaluate the existing training program to en re that personnel are trained

and knowledgeable of assigned tasks in was processing areas and of

nuclear criticality safety issues, includ g selected criticality accident

histories.

- Reevaluate all nuclear criticality sa ty analyses to ensure proper

application of the double contingenc principle, with emphasis on unsafe

geometry vessels.

- Reevaluate the audit and inspecti n programs to ensure that management

control systems are being proper y implemented.

- Review operating procedures f accuracy and completeness.

- Retrain personnel with proc ural requirements with emphasis on mandatory

compliance.

No specific action or written esponse is required by this Information Notice.

If you have any questions, p ase contact the technical contacts listed below or

the Regional Administrator the appropriate regional office.

Richard E. Cunningham, Director

Division of Industrial and

Medical Nuclear Safety

Office of Nuclear Material Safety

and Safeguards

Technical Contacts: Edward McAlpine, Region II

(404) 331-5547 W. Scott Pennington, NMSS

(301) 492-0693 Attachments:

1. Informa on Notice No. 89-24, Nucler Criticality Safety, dtd arch 6, 1989

2. List f Recently Issued

NM S Information Notices

3. List of Recently Issued

C Information Notices

EKrau/: 9/ /90

OFC:IMUF: W INM§@ IMUF. IMSB , DD/IMNS: D/IMNS:

NAME:WSPennington:mh:RWilson:VLTharpe:GHBidinger:CHau joblom:RCunningham:

____:________ ___//0----------- -- --------- /--------------/90:/7 DATE:9kt*/90: 9/3.f/90 9/lW -9-0-: -9-/q/90-:--- 9;/90: 9/ /90: 9/2Sl90: